Safety Pilot Landmark Accident: Not so easy

Modification-induced accident claims singer's life

December 1, 2012

ByBruce Landsberg

One of the joys of aviation in the United States is the ability to design, build, and fly your own aircraft. We are allowed to modify kits, but then have to deal with the consequences—good or bad. Singer and songwriter John Denver died more than 15 years ago on October 12, 1997, when his then recently purchased, modified Long-EZ Experimental crashed into the ocean near Pacific Grove, California.

The flight

The pilot called to have the aircraft readied for flight on a beautiful VFR October afternoon. He had purchased it several weeks earlier and after having it painted, had completed a quick checkout.

Just prior to the accident, the aircraft maintenance technician who assisted the pilot in moving the aircraft from the hangar noted that the pilot took his time in preflighting and borrowed a fuel strainer. The pilot declined to have the aircraft refueled and departed at 5:12 p.m. Pacific Daylight Time.

After three touch and goes, the Long-EZ departed the pattern around 5:27 p.m. and there was no further radio contact. Shortly after, 20 witnesses saw the aircraft spiral into the ocean in a steep right bank, approximately 150 yards offshore, from an estimated altitude of 350 to 500 feet. “Eight of the witnesses said that they heard a ‘pop’ or ‘backfire,’ along with a reduction in the engine noise level, just before the airplane descended into the water,” according to the NTSB report.

The wreckage was found in 30 feet of water and most components were recovered. No discrepancies could be found in the engine or flight control system.

The pilot and checkout

According to the NTSB, John Denver “held a private pilot certificate, with airplane ratings for single and multiengine land, single-engine sea, and gliders. He also held an instrument airplane rating and a Learjet type rating. On his most recent medical application of record, dated June 13, 1996, he reported a total flight time of 2,750 hours.”

A Long-EZ pilot provided Denver with a half-hour ground and flight checkout in the accident airplane in Santa Maria, California, on the day before the accident. They performed two touch-and-go landings and some slow-flight maneuvers, and discussed the aircraft systems, including the fuel system. Although Denver had taken several demo flights in the aircraft prior to purchase, his time in type—although limited—could not be determined.

The aircraft

The Experimental amateur-built, canard-type aircraft was issued an airworthiness certificate from the FAA’s Houston Flight Standards District Office in June 1987. It was equipped with a single-axis (roll) autopilot, but the autopilot was not recovered. The kit was originally designed to have a 100- to 115-horsepower engine but the builder had elected to install a 150-hp engine. This modification was made on a number of Long-EZs and required 50 pounds of ballast in the nose, to balance the additional weight of the heavier rear-mounted engine.

The NTSB estimated that two batteries in the nose weighed approximately 41 pounds and that the aircraft, at the time of the accident, would have been almost within weight and balance prescribed by the kit designer, Scaled Composites/Rutan Aircraft. The plans called for an aft center-of-gravity limit of 103 inches. The accident aircraft was estimated at 103.65 inches, although a design aircraft had been test flown with a CG as far aft as 106 inches. However, designer Burt Rutan preferred a more conservative number. The weight of Denver’s aircraft was well within limits.

An additional modification had been made to the fuel system. The original design located the fuel selector between the pilot’s legs in the front cockpit. However, the builder stated that he did not like having fuel lines in the cockpit and had moved the selector to the aft bulkhead, behind the pilot’s left shoulder. According to the NTSB, “The selector valve was installed inside the engine firewall 45 inches aft of the selector handle. The handle and valve were joined by steel and aluminum tubing, connected by a universal joint.” There were no placards on the selector to indicate position.

The NTSB continues, “The fuel quantity is determined by viewing non-linear sight [level] gauges located in the rear cockpit at the wing roots. The sight gauges show an amount of actual fuel supporting a red float. Post-accident examination of the airplane disclosed that the sight gauges were not marked or calibrated for quantity.”

The airframe and engine had about 850 total flight hours and the last FAA-required, 12-month condition inspection had taken place September 20, 1997.

Analysis

The Long EZ was sold by the builder to a buyer in March 1994, who subsequently sold the aircraft to Denver on September 27, 1997. The aircraft was repainted in Santa Ynez, California, and flown to Santa Maria, where the checkout took place. Denver then flew the airplane to Monterey.

The maintenance technician in Monterey said he and Denver had discussed the poor location of the cockpit fuel selector valve handle and that it was very hard to turn. The report notes, “They attempted to extend the reach of the handle, using a pair of vice grip pliers. But this did not solve the problem, as the pilot still could not reach the handle while seated. The pilot said he would use the autopilot in flight, if necessary, to hold the airplane level while he turned the fuel selector valve.”

The technician provided him with an inspection mirror, which was recovered from the wreckage, to view the fuel sight gauges on the rear bulkhead. Arrangements had been made to relocate the fuel selector while Denver was away on tour in the near future.

Fuel starvation appears to have been the reason why the engine stopped. The Long-EZ had an estimated 19 gallons on board when it departed Santa Maria. According to the check pilot, the fuel selector was positioned to the right tank with about 12.5 gallons. The NTSB estimated the trip to Monterey would burn between 6.4 and 9.1 gallons, depending on power setting, and the accident flight consumed between three and four gallons. That’s a high probability that the right tank was empty at a most inconvenient time and altitude.

Scaled Composites flew the same profile in a similar Long-EZ and after running one tank dry, it took six to eight seconds to restart. It was likely that the test pilot was expecting the failure, responded almost immediately, and that the fuel selector handle could be properly repositioned quickly.

The NTSB reported, “other pilots who…had flown [the accident airplane], to change the fuel selector a pilot had to: 1) Remove his hand from the right side control stick if he was hand-flying the aircraft; 2) Release the shoulder harness; 3) Turn his upper body 90 degrees to the left to reach the handle; and 4) Turn the handle to another position. Two pilots shared their experiences of having inadvertently run a fuel tank dry with nearly catastrophic consequences because of the selector and sight gauge locations.”

The check pilot said he never attempted to reposition the fuel selector in flight. An NTSB investigator noted that when he attempted the procedure, he naturally tended to push against the right rudder. A representative from Scaled Composites noted that the rudder is especially effective in inducing yaw and only a 1/8-inch displacement of the side stick would induce roll with a very strong tendency to spiral.

Probable cause

The NTSB determines the probable causes of this accident to be: “the pilot’s diversion of attention from the operation of the airplane and his inadvertent application of right rudder that resulted in the loss of airplane control while attempting to manipulate the fuel selector handle.” Also, the board determined that the pilot’s inadequate preflight planning and preparation, specifically his failure to refuel the airplane, was causal. The board determined that the builder’s decision to locate the unmarked fuel selector handle in a hard-to-access position, unmarked fuel-quantity sight gauges, inadequate transition training by the pilot, and the pilot’s lack of experience in this type of airplane were factors in the accident.

Commentary

This accident indicates how multiple factors can conspire to create a tragedy, but the good news is that it only takes one preventive action to break the accident chain. Personally, several actions are recommended because I’m never quite sure where the final link might be lurking.

Fuel is essential to powered flight. If the aircraft has multiple tanks, it doesn’t matter how much fuel is in the tank not connected to the engine.

The builder presumably wanted to make his aircraft safer by not having fuel lines in the cockpit and thus relocated the fuel valve. Two problems emerged: The valve was not safely accessible in flight, and the valve itself apparently was not easy to turn because of construction/installation issues. Placards are essential for all controls, and nonlinear fuel gauges must be calibrated and placarded lest they mislead the unwary.

Thorough transition training is essential in all aircraft, even for highly experienced pilots. Far too many mishaps occur because the pilot is not one with the machine. The FAA, NTSB, the industry, type clubs, insurance companies, and the Air Safety Institute all strongly recommend it. History proves it.

The nature of Experimental aircraft is precisely that. Some modifications work really well and a few leave one to wonder why. Many Experimental aircraft are well designed and well built. Both attributes are essential for safe flight, as is pilot familiarity with the aircraft and its systems.

Summary

Newly transitioned pilot runs a fuel tank dry at low altitude.

Loses control in attempting to switch fuel tanks.

Modification of Experimental aircraft, by moving fuel tank selector, contributes to control loss by making tank switching difficult.

Bruce Landsberg is president of the AOPA Foundation.

EcoFlight flies youth to honor John Denver

by Alton K. Marsh

When John Denver died in the crash of a Long-EZ in mid-October 1997 media reports first indicated it was a friend of Denver, not the singer himself. Bruce Gordon’s friends began calling. Denver’s death cut short a planned flight by the two friends across the country using celebrity pilots to raise awareness of environmental issues.

“I was probably one of the only friends he had that would go on the road with him and didn’t work for him,” Gordon said. “I got him interested in what I call conservation flying. We did a lot of aerial education tours.” Gordon, a pilot, went on to found EcoFlight, an Aspen, Colorado, based organization that provides flights for property owners, government officials, and the press. Denver became a voice for conservation, and brainstormed ideas with Gordon for environmental awareness. One of those was “Flight Across America” that would start in Anchorage, ending in Washington, D.C., on Earth Day 2000.

As a memorial to Denver, the flight continues today as an educational program for youth organized by EcoFlight Vice President Jane Pargiter, a pilot and teacher from South Africa. Once the EcoFlight missions are over for the year, some of the youth the organization has worked with through educational programs are given a flight lasting several days—the Flight Across America. This year the flight studied the Colorado River.

Gordon said his organization is not opposed to gas and oil drilling, but wants the effects of those industries studied to prevent damage to wilderness and recreational areas that are critical to local economies. Days before he was interviewed for this story he had flown an Associated Press reporter working on a story about a wilderness bill now before Congress.

AOPA is calling on its members to take immediate action to build support for new legislation that would reform the third class medical process and provide other protections for general aviation pilots.